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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3617_Библиотеки_им_академика_М_И_Перельмана
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Fig. 4.7j After the clipped branches have been cut, the aneurysm is excised.
MCA-to-MCA Bypass 135
Fig. 4.7k The cut ends of the proximal MCA and two distal MCA branches are prepared for a Figure 8 anastomosis.
Fig. 4.7l The fi rst distal MCA branch is anastomosed to the proximal MCA with a running suture.
136 Color Atlas of Cerebral Revascularization
Fig. 4.7m The anastomosis of the fi rst distal MCA branch to the proximal MCA is three-quarters complete. A
running suture is started in the second distal branch to join the two medial walls. Diagram of continuous Figure 8
shows suturing sequence.
Fig. 4.7n The running suture continues around the second distal branch to complete the Figure 8 anastomosis.
Fig. 4.7o The Figure 8 anastomosis from the proximal MCA to the two distal branches is completed. The temporary
clips are removed to check the patency of the bypass.
MCA-to-MCA Bypass 137
Fig. 4.7p Intraoperative ICG angiogram confi rms patency of both
channels.
Fig. 4.7q An STA-to-distal MCA anastomosis is performed to vascularize the remaining distal branch of the MCA aneurysm.
Fig. 4.7r Intraoperative ICG angiogram
demonstrates patency of the STA-to-MCA bypass
(arrow).
138 Color Atlas of Cerebral Revascularization
Fig. 4.7s, t Anteroposterior and lateral ICA angiograms confi rm patency of the bypass (arrows) of the proximal MCA
branch to the two distal MCA branches.
Fig. 4.7u Lateral ECA angiogram demonstrates patency of the
STA to the remaining MCA branch.
Fig. 4.7v Postoperative CT shows no ischemic regions. The patient made an
excellent recovery.
ts
5 MMA-to-MCA Bypass
140 Color Atlas of Cerebral Revascularization
The MMA is a small vessel with fairly robust fl ow under normal conditions. If the STA is unsuitable or if a
second vessel is needed for bypass to the territory of the MCA, the MMA may be considered as a donor vessel.
In certain pathological conditions, such as in the presence of some tumors, the MMA substantially enlarges,
making it more suitable for use in a bypass.
Fig. 5.0a In this anatomical specimen, the MMA is visible through a frontotemporal
craniotomy. (Photograph used with permission from Journal of Neurosurgery .)
MMA-to-MCA Bypass 141
Fig. 5.0b The major trunk of the MMA has been dissected free. (Photograph used with
permission from Journal of Neurosurgery .)
Fig. 5.0c The MMA has been anastomosed to a cortical branch of the MCA.
(Photograph used with permission from Journal of Neurosurgery .)
142 Color Atlas of Cerebral Revascularization
Case 5-1
Diagnosis: Left parafalcine meningioma with MCA
occlusion and ACA-to-MCA collateralization
Bypass: MMA-to-MCA
Approach: Right temporal
Fig. 5.1a Axial CT shows a high-density lesion
consistent with a right falcine meningioma.
(Used with permission from Journal of
Neurosurgery .)
MMA-to-MCA Bypass 143
Fig. 5.1b Right ICA angiogram shows
draped vessels ( arrowheads ) and an unrelated
occlusion ( arrow ) of the MCA. (Used with
permission from Journal of Neurosurgery .)
Fig. 5.1c Right ECA angiogram shows the STA
( double arrows ) and large-caliber MMA ( arrow ).
Distal branches of the MMA ( arrowhead ) feed
the tumor. (Used with permission from Journal
of Neurosurgery .)
144 Color Atlas of Cerebral Revascularization
Fig. 5.1d Overview shows the blood supply of the
tumor, which is fed by the enlarged MMA and its
branches as well as by the distal vessels of the MCA.
In response to the occlusion at the origin of the MCA,
the distal MCA is supplied by retrograde fl ow ( arrows )
through collateral vessels of the ACA.
Fig. 5.1e The MMA-to-MCA bypass diverts MMA
blood fl ow away from the tumor and supplies the
proximal and distal distribution ( arrows ) of the MCA.
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